Every finding on record at Clearview Home

Based on clinical record review, staff interviews, facility investigative file review, and facility policy review the facility failed to ensure 2 of 3 residents (Resident #3 and #4) were free from abuse. Staff had used their personal cell phones to take a photo of Resident #3 and a video of Resident #4 without their consent. The facility reported a census of 70 residents.Findings include:The facility corrected the deficient practice per past noncompliance on 5/22/2026 through the following actions: -all facility staff educated on the facility's Abuse Policy,-all facility staff educated on the facility's HIPPA Policy,-all facility staff educated on the facility's Social Media Policy,-the facility's Cell Phone Policy was updated,-all facility staff educated on the facility's Cell Phone Policy. 1. According to an annual Minimum Data Set (MDS) assessment tool with a reference date of 2/27/2026 documented Resident #3 had a Brief Interview of Mental Status (BIMS) score of 0. A BIMS score of 0 suggested severe cognitive impairment. The MDS documented she was dependent on staff for toileting hygiene and toilet transfers. Resident #3 was always incontinent of bowel and bladder. The MDS listed the following diagnoses for Resident #3: dementia, anemia, renal failure, arthritis, anxiety, depression, overweight, diarrhea, and metabolic encephalopathy.A Care Plan Focus Area with a revision date of 6/27/2025 documented Resident #3 required assistance with Activities of Daily Living (ADLs), utilized a mechanical lift for transfers and not independently mobile. She required the assistance of two staff for transfers and the use of a mechanical lift for all transfers.A second Care Plan Focus Area with a revision date of 7/15/2024 documented Resident #3 required the assistance of two staff to use the toilet or bedside commode. The Care Plan documented she worse an adult brief as she was always incontinent of bowel and bladder. Staff were encouraged to check and change Resident #3 and anticipate her needs.The facility investigative file including the following:-Summary of findings: the Director of Nursing (DON) received a call on 5/16/26 from a community member that she had been contacted about an inappropriate snapchat taken by Staff K Certified Nursing Assistant (CNA) on 5/16/2026 at approximately 3:45 PM. The DON immediately notified the Assistant Administrator, who had just received a phone from another community member asking where they were as she had something important to tell him. The DON and Assistant Administrator went immediately to facility and removed Staff K from the floor to begin interviewing her. Staff K did confess to taking a snap chat at approximately 2:30 PM of a soiled brief (with stool present) that was on Resident #3. Staff K stated the snapchat was of the resident's lower thighs with the soiled brief unfolded between her legs. Staff K stated it did not have peri area in the photo but she sent it to one of her friends via snap chat. This friend was not a facility staff member. Staff K denied saving the photo on her phone and acknowledged that she knew it was not appropriate. Staff K stated she had been educated on dependent adult abuse policy, social media policy, and cell phone policy. When asked if she had ever taken photos of residents in the past she said no, but said she had taken photos of soiled briefs or linens in the utility room before with no residents present. When asked if she had ever heard reports or seen this happen with other staff, she said no. Staff K's employment was terminated.-The Deputy Sheriff was notified and he was informed they needed to know the details/content of the snapchat and he confirmed he would interview the community member about the snap tomorrow and report back to the facility. -On 5/18/2026 the Deputy Sheriff called and discussed his interview. The community member stated they did have the picture because it was on snapchat. They stated they saw legs and a complete blowout in the brief and couldn't tell if it showed complete nudity because blowout was so bad. The community member told the Sheriff this was not the first time this has happened. The facility asked if the past pictures included residents or not and the Sheriff said he would ask and get back in touch. -On 5/20/2026 the Sheriff called the Assistant Administrator and informed him that the community member said the past snaps were only of soiled linens and briefs, no person or skin ever in the photos. -Corrective Action: Immediately separated Staff K from all residents and did terminate her effective immediately. On 5/16/2026 all staff received abuse policy, cell phone policy, and social media policy. Follow-up interviews with all nurses were conducted asking if they witnessed Staff K on her cell phone taking pictures or videos or if ever received reports of such behavior; they all denied this. The Administration and department heads reviewed and revised cell phone policy. Staff in-service was held 5/21/2026 to review updated cell phone policy and again reviewed abuse policy, social media policy, and HIPPA. On 5/27/2026 at 2:09 PM the Assistant Administrator stated he got a call from the DON stating they have a problem. She had received a call from a community member about Staff K taking photos of a resident on snapchat. He also had a community member call to report a Staff K had taken a snapchat photo of a resident's soiled brief at approximately 2:30 PM on 5/16/2026. The DON and himself went to the facility and Staff K stated the photo was of Resident #3's thighs and a soiled brief was unfolded between her legs. Staff K admitted to sending it to someone that was not a facility staff member and the photo was not saved on her phone. Staff K acknowledged it was not appropriate and the only other photos she had taken while at work were of soiled briefs and linens. The Assistant Administrator stated Resident #3 would not be capable of answering if it was ok to take the photo.On 5/29/2026 at 11:09 AM the DON stated a community member called to tell her about a video that Staff K had sent out of a resident's brief full of stool. The DON called the Assistant Administrator and he said another community member wanted to talk to him, they assumed it was of the same issue. When they both arrived at the facility, they pulled Staff K in to talk to her. She admitted to taking the photo of Resident #3's upper thighs and her soiled brief pulled down. Staff K denied any of the resident's peri-area in the photo on snapchat. Staff K could not say why she took the photo but was able to tell them the photo was of Resident #3's soiled brief. The DON stated she had heard of Staff K taking photos while in the dirty utility room of dirty briefs. The DON attempted to talk to Resident #3 about what happened but she had no idea what had taken place. They started to do education that night on the following policies: cell phone, social media, and abuse. They initiated that all cell phones are to be placed in a basket and placed in a locked medication cart at the beginning of each shift. 2. According to a significant change MDS assessment tool with a reference date of 2/28/2026 documented Resident #4 had a BIMS score of 5. A BIMS score 5 suggested severe cognitive impairment. The MDS documented he required supervision or touching assistance for toileting hygiene, was independent to go from a sitting to standing position and toilet transfers. The MDS documented he was occasionally incontinent of urine and frequently incontinent of bowel. The MDS listed the following diagnoses for Resident #4: encephalopathy, cancer, benign prostatic hyperplasia, renal failure, urinary tract infection (UTI), dementia, depression, and neutropenia.A Care Plan Focus Area with a revision date of 4/6/2026 documented Resident #4 was independent without assisted devices for transfers and ambulation.A Progress Noted documented on 4/1/2026 at 12:37 PM documented Resident #4 was discharged to another facility's memory care unit.The facility investigative file included the following:-On 5/20/2026 Staff G Certified Nursing Assistant (CNA) signed and dated the following typed statement: I was walking into the locker room at school when Staff I CNA said Hey look at this and she had put her phone in front of me. It was a video of a male resident; I don't remember his name. He was standing in the chapel with his back to the chapel door and I could hear him peeing into the trashcan as the video zoomed in on him. Staff I's face was also halfway in the photo. We both laughed, then the bell rang so I left to go to class. I don't remember how long ago it happened, probably over a month ago. I did not report it because I did not feel like I saw anything inappropriate in the video because he was fully dressed. -Summary of Findings: the Director of Nursing (DON) was notified by Staff H Registered Nursing (RN) on 5/19/2026 at approximately 8:45 PM that Staff G had notified her of a video she had seen on another employee's phone. The video was of a male resident urinating in a trashcan in the chapel. The DON called Staff G on 5/19/2026 at approximately 9:30 PM to confirm. Staff G reported that she was in the locker room at school, she could not remember the date but reports it was over a month ago, when Staff I showed her the video. Staff G stated the video was of half of Staff I's face with a male resident in the background with his back to the camera. Staff G stated that she could hear him urinating but there was no context on the video. Staff G stated the man was fully clothed. The DON did check the CNA schedule and confirmed Staff I was not on the schedule for that evening, late night or the next morning. No resident assessment completed as Resident #4 had been discharged to an assisted living facility closer to facility on 4/1/2026. The DON and Social Worker entered Resident #4 on 5/20/2026 at approximately 9:00 AM. The DON asked if Staff I knew why they were interviewing her and she said yes, I think so. Staff I was asked if she ever sent a video of residents to anyone and she said, yes. Staff I acknowledged the video was of a male resident urinating in a trash can in the chapel. Staff I stated she sent the video in a snapchat group consisting of 5 other CNAs at the facility. Staff I stated she no longer had the video on her phone. The DON questioned Staff I on how she was able to show the video to someone at a later time in the school locker that was not in a snapchat group if it was not saved on her phone. Staff I stated I don't remember but the video is not on my phone anymore. Staff I was asked if there were any other residents in the video, she stated no just him. Staff I stated she was sitting in center lobby; I turned my phone camera to selfie mode and I could see Resident #4 standing inside the chapel door peeing in a trashcan with his back to her. He was completely dressed, there was no nudity in the photo at all. Staff I stated the photo was taking a while ago, like months ago. When asked if she had taken pictures or videos of any other residents on her phone, she stated yes but it was taken at a wrestling meet. Staff I showed the DON and Social Worker of a photo of herself with a previous resident sitting on the [NAME] in the high school gym, smiling for the camera. The five staff members in the snap chat group were asked if they were sent or viewed a snapchat video of a male resident urinating in a trashcan in the chapel at the facility. All five denied seeing or receiving a video. Due to Staff I claiming she sent it via snapchat and the fact that she showed Staff G at a later time, we reinterviewed Staff I in the afternoon of 5/20/2026 to ensure Staff I had gone through her phone as to whether or not she could produce the snapchat video or if it was a video in her camera roll. Staff I stated she went through her snapchat as well as her phone gallery and that the video was no longer on her phone. At this time Staff I stated that the video was only of her face, that the resident wasn't visible in the snap. She was asked why she had originally stated that morning that the resident was visible but now wasn't. Attempted to clarify as another staff member had reported Staff I had zoomed in on the trash can the resident was urinating in. Staff I denied zooming in on anything and continued to stated the resident was never visible in the video she had taken. Staff I was re-interviewed on 5/22/2026 at 11:10 AM due to having more questions, her changes regarding the incident. When asked what the video was of, she stated myself and a caption that stated Resident #4 is peeing in the trash can. She denied zooming in on the trash can and that she was sitting outside the chapel with another resident. At that time she heard someone starting to pee in the trash can. Staff I stated she could not remember exactly but did not think Resident #4 was at all visible in the video. Staff I was terminated on 5/20/2026. -The facility's cell phone policy was updated on 5/21/2026. An all-staff in-service was completed on 5/21/2026 related to recent incidents, again discussing the abuse policy, social media policy, HIPPA, and went over the updated cell phone policy. Those staff that were not present at the in-service are being visited with 1-1 by administration.On 5/28/2026 at 9:35 AM Staff E CNA stated staff are not allowed to take photos or videos of residents with their cell phones. When asked what if it's a photo without the resident's face in it, she said absolutely not.On 5/28/2026 at 9:51 AM Staff H Registered Nurse (RN) stated she received a text from a staff member about an incident and she told that staff member it needed to be reported. Staff G came up to another staff member and asked if they were part of a group snapchat because apparently, they send photos and videos of residents all the time. Staff H called the DON to tell her what she was informed of regarding the group snapchat. Staff H stated she did not see any photos or videos, just that she was told they sent them in a snapchat group. When asked if staff are allowed to take photos or videos of residents, she stated absolutely not; even if there were no identifying characteristics of the resident.On 5/28/2026 at 10:25 AM Staff C CNA denied ever seeing photos or videos of residents on staff's phones. She added staff are not allowed to take photos of residents with their phones. When asked what if the resident's face was not showing, could the photo be taken she said no she would not even take a photo of an injury if the nurse asked her to.On 5/28/2026 at 10:29 AM Staff D CNA stated she has not seen any photos of residents on other staff members' phones. She stated staff are not allowed to take photos of residents with their phones even if the photos do not include the resident's face. She added they are not allowed to take photos of residents or anything to do with them.On 5/28/2026 at 10:44 AM Staff F CNA stated only activity staff are allowed to take photos of residents. When asked if floor staff can take photos of residents even if their faces are not included, she stated no. On 5/28/2026 at 10:59 AM Staff G stated she was in the high school locker room when Staff I said look at this, it's funny. On Staff I's phone was a video of a male peeing in a trash can in the chapel at the facility. The school bell rang, so she went to class. She did not recognize the male, he was fully clothed, there were no other resident present. This video was on Staff I's snapchat app and did not say if she had sent it to anyone. Staff G acknowledged she did not tell anyone about this. She stated from the time she saw the photo to the time it was reported to the facility it was probably longer than a month. She did not see any naked parts of the man and did not feel it was severe enough issue to report it. She stated after the DON interviewed her, they went over the handbook for HIPPA, cell phones are to be in the medication cart locked up and they went over the social media policy too. She added only the activity department is allowed to take any photos.On 5/28/2026 at 12:10 PM the Social Worker stated when her and the DON spoke to Staff I she acknowledged to taking the video of Resident #4 and she should not have done it. Staff I stated she knew it was stupid and should not have done it. When asked to talk about the video, Staff I stated she was on the couch outside of the chapel and another resident was sitting with her. She went to take a selfie and noticed Resident #4 was in the chapel with his back towards her, urinating in a trash can. Staff I stated it was Resident #4 and she had sent it in a group snapchat with 5 other staff members. When they interviewed those other staff members they denied seeing this video of Resident #4.On 5/28/2026 at 12:42 PM Staff B Registered Nurse (RN) stated she has not seen any photos or videos of residents on staff's phones. She indicated staff are not allowed to take photos or videos are residents with their phones even if there is nothing to identify the resident in the photo such as a hand.On 5/29/2026 at 11:23 AM the DON stated Staff H had called her at home on 5/19/2026 to let her know there is a snapchat group that had an inappropriate picture in it and just wanted her aware. The DON called the Assistant Administrator to inform him. They called Staff G and she stated she was in the school locker room when Staff I said look at this. Staff I got her phone out and showed a video of a guy in the background and Staff I's face in the frame. The guy was peeing in a trash can in the chapel. The video zoomed in on the trash can but the guy was fully dressed and had his back to the phone. When they asked Staff G why she did not report it she told them she did not see any nudity so she did not feel like it needed to be reported. The DON let her know that if she ever had a question about whether something should be reported, to report it. The DON and the Social Worker interviewed Staff I and she admitted to sending a video of a resident urinating in a trash can, to five staff members in a snapchat group. She denied having the video on her phone but they questioned how she was able to show Staff G the video if it was not on her phone. Staff I stated she did not know but it was not on her phone anymore. Staff I stated this took place about a month ago and had no other photos or videos of residents on her phone. Staff I stated the video was in selfie mode and she could see Resident #4 peeing in the background. She stated the resident was fully clothed, no nudity at all. When they spoke to the five girls in the snapchat group, they could not recall seeing or receiving a video of that. If they did, they stated they would have reported it. When the DON called Staff I to clarify a few things, she stated it was just her face in the video, not the resident. She reported it was a selfie with a caption that said Resident #4 peeing in the can. Staff I was terminated and education to all staff was started. The DON stated staff are not to take photos or videos of residents even if there are no identifying characteristics included.The facility provided a document titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy. The policy documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility provided a document titled Social Media Policy. The policy documented personal use of social media is never permitted on working time. DO NOT use social media to post, upload, send, or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or resident's authorized agent as required by applicable law. This prohibition includes photos and videos where the resident is not easily identifiable (a photo of the resident's hand, a close up photo of any part of a resident's body or a photo of the back of a resident in the far background of the photo).The facility provided a document titled Cell Phone, Gaming Systems, and Laptop Computers policy with a revision date of 5/21/2026. Purpose-to provide the resident with privacy and dignity & maintain a loving and caring environment without interruptions or distractions in care. Policy - Cell phones, gaming systems and laptop computers are not allowed in the facility. If your children, family, or school needs to contact you, they are welcome to call here, as they always have been able to do in the past. Due to Federal HIPPA Privacy Laws and cell phones having cameras, this policy has become necessary. There is no tolerance or leeway regarding this policy.

Based on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to report when facility staff had taken a video on their cell phone of Resident #4 and shared it with a snapchat group chat. The facility reported a census of 70 residents.Findings include:The facility corrected the deficient practice per past noncompliance on 5/22/2026 through the following action: -all facility staff educated on the facility's Abuse PolicyAccording to a significant change MDS assessment tool with a reference date of 2/28/2026 documented Resident #4 had a BIMS score of 5. A BIMS score 5 suggested severe cognitive impairment. The MDS documented he required supervision or touching assistance for toileting hygiene, was independent to go from a sitting to standing position and toilet transfers. The MDS documented he was occasionally incontinent of urine and frequently incontinent of bowel. The MDS listed the following diagnoses for Resident #4: encephalopathy, cancer, benign prostatic hyperplasia, renal failure, urinary tract infection (UTI), dementia, depression, and neutropenia.A Care Plan Focus Area with a revision date of 4/6/2026 documented Resident #4 was independent without assisted devices for transfers and ambulation.A Progress Noted documented on 4/1/2026 at 12:37 PM documented Resident #4 was discharged to another facility's memory care unit.The facility investigative file included the following:-on 5/20/2026 Staff G Certified Nursing Assistant (CNA) signed and dated the following typed statement: I was walking into the locker room at school when Staff I CNA said Hey look at this and she had put her phone in front of me. It was a video of a male resident; I don't remember his name. He was standing in the chapel with his back to the chapel door and I could hear him peeing into the trashcan as the video zoomed in on him. Staff I's face was also halfway in the photo. We both laughed, then the bell rang so I left to go to class. I don't remember how long ago it happened, probably over a month ago. I did not report it because I did not feel like I saw anything inappropriate in the video because he was fully dressed.-Staff G was questioned as to why she did not report this at the time. Staff G stated she did not feel like it was something that needed to be reported because he was fully dressed and didn't see anything inappropriate. She did acknowledge that she had taken the mandatory reporting class as well as training upon hire. Immediate education done with Staff G on dependent adult abuse reporting and if she ever questioned whether it is something that should be reported to always just report to your supervisor.-Summary of Findings: the Director of Nursing (DON) was notified by Staff H Registered Nurse (RN) on 5/19/2026 at approximately 8:45 PM that Staff G had notified her of a video she seen on another employee's phone. The video was of a male resident urinating in a trashcan in the chapel. The DON called Staff G on 5/19/2026 at approximately 9:30 PM to confirm. Staff G reported that she was in the locker room at school, she could not remember the date but reports it was over a month ago, when Staff I showed her the video. Staff G stated the video was of half of Staff I's face with a male resident in the background with his back to the camera. Staff G stated that she could hear him urinating but there was no context on the video. Staff G stated the man was fully clothed. The DON did check the CNA schedule and confirmed Staff I was not on the schedule for that evening, late night or the next morning. No resident assessment completed as Resident #4 had been discharged to an assisted living facility closer to facility on 4/1/2026. The DON and Social Worker entered information about Resident #4 on 5/20/2026 at approximately 9:00 AM. The DON asked if Staff I knew why they were interviewing her and she said yes, I think so. Staff I was asked if she ever sent a video of residents to anyone and she said, yes. Staff I acknowledged the video was of a male resident urinating in a trash can in the chapel and she said yes. Staff I stated she sent the video in a snapchat group consisting of 5 other CNAs at the facility. Staff I stated she no longer had the video on her phone. The DON questioned Staff I on how she was able to show the video to someone at a later time in the school locker room that was not in a snapchat group if it was not saved on her phone. Staff I stated I don't remember but the video is not on my phone anymore. Staff I was asked if there were any other residents in the video, she stated no just him. Staff I stated she was sitting in center lobby; I turned my phone camera to selfie mode and I could see Resident #4 standing inside the chapel door peeing in a trashcan with his back to her. He was completely dressed, there was no nudity in the photo at all. Staff I stated the photo was taken a while ago, like months ago. Staff I was re-interviewed on 5/22/2026 at 11:10 AM due to having more questions, her changes regarding the incident. When asked what the video was of, she stated myself and a caption that stated Resident #4 is peeing in the trash can. She denied zooming in on the trash can and that she was sitting outside the chapel with another resident. At that time, she heard someone starting to pee in the trash can. Staff I stated she could not remember exactly but did not think Resident #4 was at all visible in the video. Staff I was terminated on 5/20/2026.-The facility's cell phone policy was updated on 5/21/2026. An all-staff in-service was completed on 5/21/2026 related to recent incidents, again discussing the abuse policy, social media policy, HIPPA, and went over the updated cell phone policy. Those staff that were not present at the in-service are being visited with 1-1 by administration. On 5/28/2026 at 9:35 AM Staff E CNA stated if someone showed her a photo of a resident on their phone, she would take it to her supervisor.On 5/28/2026 at 9:45 AM Staff J CNA stated if someone were to show her a photo of a resident on their phone, she would immediately report it to the DON, Assistant Director of Nursing (ADON) or Administrator. She added even if the photo did not have an identifying characteristic of a resident, she would still report it.On 5/28/2026 at 9:51 AM Staff H Registered Nurse (RN) stated she received a text from a staff member about an incident and she told that staff member it needed to be reported. Staff G came up to another staff member and asked if they were part of a group snapchat because apparently, they send photos and videos of residents all the time. Staff H called the DON to tell her what she was informed of regarding the group snapchat. Staff H stated she did not see any photos or videos, just that she was told they sent them in a snapchat group. She stated she would immediately report it if someone sent or showed her a photo of a resident. They have provided education to staff on the reporting requirements.On 5/28/2026 at 10:25 AM Staff C CNA stated if someone showed her a photo of a resident on their phone, she would speak up and go to the charge nurse to report it.On 5/28/2026 at 10:29 AM Staff D CNA stated if she was aware of a staff member with a photo of a resident on their phone, she would report it to the DON or ADON as soon as possible (ASAP).On 5/28/2026 at 10:44 AM Staff F CNA stated if someone sent her or showed her a photo of a resident, she would take that person to the charge nurse, DON, or Administrator. She would remove that staff person from the room so they could not take more photos. If one was sent to her, she would go to the charge nurse.On 5/28/2026 at 10:59 AM Staff G stated she was in the high school locker room when Staff I said look at this, it's funny. On Staff I's phone was a video of a male peeing in a trash can in the chapel at the facility. The school bell rang, so she went to class. She did not recognize the male, he was fully clothed, there were no other resident present. This video was on Staff I's snapchat app and did not say if she had sent it to anyone. Staff G acknowledged she did not tell anyone about this. She stated from the time she saw the photo to the time it was reported to the facility it was probably longer than a month. She did not see any naked parts of the man and did not feel it was severe enough issue to report it.On 5/28/2026 at 12:42 PM Staff B Registered Nurse (RN) stated if someone were to show her a photo or video of a resident on their phone, she would take the phone away, remove the staff member immediately then call the DON, then send the staff member home.On 5/29/2026 at 11:23 AM the DON stated Staff H had called her at home on 5/19/2026 to let her know there is a snapchat group they had an inappropriate picture in it and just wanted her aware. The DON called the Assistant Administrator to inform him. They called Staff G and she stated she was in the school locker room when Staff I said look at this. Staff I got her phone out and showed a video of a guy in the background and Staff I's face in the frame. The guy was peeing in a trash can in the chapel. The video zoomed in on the trash can but the guy was fully dressed and had his back to the phone. When they asked Staff G why she did not report it she told them she did not see any nudity so she did not feel like it needed to be reported. The DON let her know that if she ever had a question about whether something should be reported, to report it.The facility provided a document titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy. All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 73 residents. Findings include: On 9/9/24 at 3:02 PM, Resident #20's Electronic Health Record (EHR) information was visible on an open laptop on the medication cart in front of the South hall nurses' station. There were ambulatory residents within the vicinity and no staff were present. At 3:07 pm, Staff A, Registered Nurse (RN) stated she thought she locked the laptop screen. She also stated the laptop screen's should be locked when staff is away from it. An undated document titled HIPAA Health Insurance Portability and Accountability Act of 1996 indicated if someone asks for information, or is accessing it, workforce members should know who the person is, and that the person is allowed to look at that information. On 9/11/24 at 3:38 PM, the Director of Nursing (DON) stated staff should lock the computer screen when leaving medication cart.

Based on clinical record review, facility policy review, facility investigation, family interview and staff interview the facility failed to report timely and failed to separate the alleged perpetrator from potential victims during investigation of alleged abuse for 1 of 3 residents reviewed (Resident #2). On 4/24/23 an aide reported she notified management back in December 2022 or January 2023 that a staff member took a video of a resident lying in bed with his brief exposed and posted it to her social media story. On 4/25/23 staff member confirmed she took the video back in December 2022 or January 2023 and management spoke to her at the time of the incident. The aide continued to work with all residents, including resident #2 from the time of the incident until she was terminated on 3/12/23 for taking an inappropriate video. These failures constituted an immediate jeopardy situation. On 4/25/23 at 2:42 PM, the Iowa Department of Inspections and Appeals staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility beginning 1/19/23. The facility staff removed the immediacy on 4/26/23, and decreased the scope to a D, after the facility staff completed the following: a. Re-education with all staff on the facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019. b. Re-education with all staff on the undated facility policy Social Media. The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented he scored 7 points on the Brief Interview of Mental Status (BIMS) indicating he had severe cognitive impairment. The MDS documented he was totally dependent on two people for transfers and toileting, was totally dependent on one person for hygiene and required extensive assist of one person for bed mobility and dressing. The MDS documented he had diagnoses that included coronary artery disease, hypertension, peripheral vascular disease, dementia, Parkinson's disease, depression and psychotic disorder. The Care Plan dated 5/26/22 for Resident #2 documented he had cognitive loss related to his Parkinson's disease. The Care Plan documented he had a history of hallucinations, had periods of lethargy and as more disorganized in his thinking. The facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019 documented the following: -All residents have the right to be free from abuse. This includes prohibiting nursing staff from taking acts that result in person degradation, including the taking and using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any form of equipment (e.g. smart phone) to take, keep, or distribute photographs and/or recordings on social media. -All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two hours after the allegation. -Should an incident or suspected abuse be reported or observed, the Administrator or designee will investigate the alleged incident. -The Administrator or designee will complete documentation of the allegation of resident abuse and collect supporting documents relative to the alleged incident. This includes assessing the resident for injury and proper notification to the primary care provider and responsible party. -The facility will establish and enforce an environment that encourages individuals to report allegation of abuse without fear or recrimination or intimidation. -Upon receiving a report of an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents. The Facility Investigation dated 3/11/23 documented it was reported to the Director of Nursing (DON) on 3/11/23 that Staff D had taken a snapchat of a resident and had sent it to a former employee. The report documented the facility placed the aide, Staff D, on suspension until the investigation completed. Staff D stated she took the snapchat of Resident #2 laying in his bed, partially clothed, and sent it to a coworker at that time. Administration terminated employment with Staff D on 3/12/23. The report documented that Staff D stated the video was of the resident lying in bed pulling the stuffing out of his brief with no caption. The report documented the facility interviewed the other employee and she confirmed it was of the resident lying in bed pulling at the stuffing in his brief. The snapchat deleted after it was viewed so the facility was unable to see it. On 4/19/23 at 10:45 AM the nurse, Staff C, stated Staff D took a video of Resident #2 well over a month ago and management tried to cover it up. She stated the Assistant Administrator was aware of it but did not report it right away and allowed Staff D to continue to work until 3/11/23 when she was let go for another incident. She stated the only reason management reported the video incident that Staff D took is because a family member of another resident found out about it and threatened to pull her mom out if they continued to let staff work at the facility that would video a resident's privates. She stated Staff D sent the video to former employee Staff E and that she was aware of it because Staff E told her about it. She stated Staff E told her that the Assistant Administrator asked her to lie about when it happened if the state called her. On 4/24/23 at 12:15 PM the aide Staff A stated she never witnessed Staff D using her phone to take video of a resident but she heard through talk at the facility that Staff D used her phone and took video of Resident #2 and his privates was in the video. She stated she heard it was posted on her story and she also heard it was sent to another employee but she stated she never saw it. She stated this incident happened 2-3 months prior to 3/11/23. She stated the facility did education with them early this month about HIPPA and not using their phones while working. On 4/24/23 at 12:49 PM the aide, Staff B, stated she never saw any video of the resident but she heard staff at the facility talking about it. She stated she heard that Staff D took a video of the resident in bed in his brief and that she sent it to her snapchat story. She stated she started at the facility on 3/9/23 and that it had happened prior to that because that is when she heard about it. On 4/24/23 at 1:43 PM the Social Service Director (SSD) stated she gives pamphlets to families and residents on admit that addressed HIPPA and their privacy rights. She stated on hire she was trained about abuse, privacy and confidentiality and the facility also provides an annual in-service about it. She stated the staff were recently re-educated they are not to have their cell phones on them while working. She stated the second weekend in March is when she was notified that Staff D took video of the resident. She stated the only thing she was involved in was calling the wife to inform her and then following up with the resident for any behaviors. She stated the wife was upset but understood that things happen and that kids can be stupid. On 4/24/23 at 2:57 PM when questioned Staff E and informed her it was reported that she was sent a video from Staff D of the resident in his brief, she got upset and stated that Staff D did not send her a video that Staff D put it on her snapchat story and that is when she saw it. Staff E stated she reported it to the Assistant Administrator the next morning. She stated she does not have the video. She stated she knows it happened in December or January because she has not worked there since then and it happened while she was an employee. On 4/25/23 at 8:26 AM the aide, Staff D stated when she walked into Resident #2's room to check on him she found him in bed and he had torn up his brief. She stated she took a video of it because she thought it was funny and was going to share it with his wife. She stated after taking the video she put the phone in her pocket to take care of the resident and her phone accidentally uploaded the video to her snapchat story. She stated when she noticed the video uploaded she immediately deleted the video. She stated this happened back in December or January and that management was aware of it. She stated the Assistant Administrator pulled her into his office at that time, talked to her about it and told her not to do it again. She stated it took him until March to fire her. On 4/25/23 at 10:31 AM the SSD stated if she ever saw a resident being abused she would separate the resident from the person abusing them to make sure they are safe and then she would let the charge nurse know right away. She stated she would also make sure management was aware. On 4/25/23 at 10:35 AM the aide, Staff F, stated she has been an aide at the facility for almost a year. She stated she was trained on hire of abuse and if she ever saw abuse she would separate the resident to make sure they are safe and then she would report it to her nurse immediately. She stated taking video of a resident can be seen as abuse and that they have been taught by the facility they are not supposed to use their phone to take pictures or video of residents and they are not to have their phones on them. On 4/25/23 at 10:42 AM the aide, Staff G, stated if she were to see any form of abuse she would separate them right away and then tell her charge nurse so it can be investigated. She stated they have been taught not to have their phones on them while working. She stated if she saw a staff member taking video of a resident she would tell them to stop right away and report it to her nurse. On 4/25/23 at 11:52 AM the DON stated all staff are trained on hire and annually regarding abuse, what to do and when to report it. She stated if staff see any form of abuse they are expected to separate the resident to make sure they are safe, report it right away so she can start an investigation and report it to the State Agency within two hours. On 4/25/23 at 1:55 PM when asked the Assistant Administrator, when he became aware of Staff D taking video of Resident #2 he stated he was aware prior to 3/11/23. When informed it was reported that he was informed back in December 2022 or January 2023 he agreed and stated he would check on the date specifically. He stated when Staff E reported it he immediately called Staff D into his office. He stated Staff D denied it and there was no video to prove it so he thought it was teenage drama between the two aides and didn't know if it really happened. He stated they have already done a mini-education with all the aides on phone use. He stated when another staff took pictures of a different resident on 3/11/23 this incident was brought up again so he pulled Staff D back in and she admitted to taking the video. He stated that is when he decided to terminate her. On 4/25/23 at 2:10 PM the Assistant Administrator stated he looked back through his phone and 1/19/23 is when he found out about Staff D taking the video of Resident #2.

Based on clinical record review, facility policy review, facility investigation, and staff interview the facility failed to ensure a resident was free from degradation for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented he scored 7 points on the Brief Interview for Mental Status (BIMS) indicating he had severe cognitive impairment. The MDS documented he was totally dependent on two people for transfers and toileting, was totally dependent on one person for hygiene and required extensive assist of one person for bed mobility and dressing. The MDS documented he had diagnoses that included coronary artery disease, hypertension, peripheral vascular disease, dementia, Parkinson's disease, depression and psychotic disorder. The Care Plan dated 5/26/22 for Resident #2 documented he had cognitive loss related to his Parkinson's disease. The Care Plan documented he had a history of hallucinations, had periods of lethargy and as more disorganized in his thinking. The facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019 documented the following: -All residents have the right to be free from abuse. This includes prohibiting nursing staff from taking acts that result in person degradation, including the taking and using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any form of equipment (e.g. smart phone) to take, keep, or distribute photographs and/or recordings on social media. -Upon receiving a report of an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents. The Facility Investigation dated 3/11/23 documented it was reported to the Director of Nursing (DON) on 3/11/23 that Staff D had taken a snapchat of a resident and had sent it to a former employee. The report documented the facility placed the aide, Staff D, on suspension until the investigation completed. Staff D stated she took the snapchat of Resident #2 laying in his bed, partially clothed, and sent it to a coworker at that time. Administration terminated employment with Staff D on 3/12/23. The report documented that Staff D stated the video was of the resident lying in bed pulling the stuffing out of his brief with no caption. The report documented the facility interviewed the other employee and she confirmed it was of the resident lying in bed pulling at the stuffing in his brief. The snapchat deleted after it was viewed so the facility was unable to see it. On 4/19/23 at 10:45 AM the nurse, Staff C, stated Staff D took a video of Resident #2 well over a month ago and management tried to cover it up. She stated the Assistant Administrator was aware of it but did not report it right away and allowed Staff D to continue to work until 3/11/23 when she was let go for another incident. She stated the only reason management reported the video incident that Staff D took is because a family member of another resident found out about it and threatened to pull her mom out if they continued to let staff work at the facility that would video a resident's privates. She stated Staff D sent the video to former employee Staff E and that she was aware of it because Staff E told her about it. On 4/24/23 at 12:15 PM the aide Staff A stated she never witnessed Staff D using her phone to take video of a resident but she heard through talk at the facility that Staff D used her phone and took video of Resident #2 and his privates was in the video. She stated she heard it was posted on her story and she also heard it was sent to another employee but she stated she never saw it. She stated this incident happened 2-3 months prior to 3/11/23. She stated the facility did education with them early this month about HIPPA and not using their phones while working. On 4/24/23 at 12:49 PM the aide, Staff B, stated she never saw any video of the resident but she heard staff at the facility talking about it. She stated she heard that Staff D took a video of the resident in bed in his brief and that she sent it to her snapchat story. She stated she started at the facility on 3/9/23 and that it had happened prior to that because that is when she heard about it. On 4/24/23 at 1:43 PM the Social Service Director (SSD) stated she gives pamphlets to families and residents on admit that addressed HIPPA and their privacy rights. She stated on hire she was trained about abuse, privacy and confidentiality and the facility also provides an annual in-service about it. She stated the staff were recently re-educated they are not to have their cell phones on them while working. She stated the second weekend in March is when she was notified that Staff D took video of the resident. She stated the only thing she was involved in was calling the wife to inform her and then following up with the resident for any behaviors. She stated the wife was upset but understood that things happen and that kids can be stupid. On 4/24/23 at 2:57 PM when questioned Staff E and informed her it was reported that she was sent a video from Staff D of the resident in his brief, she got upset and stated that Staff D did not send her a video that Staff D put it on her snapchat story and that is when she saw it. Staff E stated she reported it to the Assistant Administrator the next morning. She stated she does not have the video. She stated she knows it happened in December or January because she has not worked there since then and it happened while she was an employee. On 4/25/23 at 8:26 AM the aide, Staff D stated when she walked into Resident #2's room to check on him she found him in bed and he had torn up his brief. She stated she took a video of it because she thought it was funny and was going to share it with his wife. She stated after taking the video she put the phone in her pocket to take care of the resident and her phone accidentally uploaded the video to her snapchat story. She stated when she noticed the video uploaded she immediately deleted the video. She stated this happened back in December or January and that management was aware of it. She stated the Assistant Administrator pulled her into his office at that time, talked to her about it and told her not to do it again. She stated it took him until March to fire her. On 4/25/23 at 10:31 AM the SSD stated if she ever saw a resident being abused she would separate the resident from the person abusing them to make sure they are safe and then she would let the charge nurse know right away. She stated she would also make sure management was aware. On 4/25/23 at 10:35 AM the aide, Staff F, stated she has been an aide at the facility for almost a year. She stated she was trained on hire of abuse and if she ever saw abuse she would separate the resident to make sure they are safe and then she would report it to her nurse immediately. She stated taking video of a resident can be seen as abuse and that they have been taught by the facility they are not supposed to use their phone to take pictures or video of residents and they are not to have their phones on them. On 4/25/23 at 10:42 AM the aide, Staff G, stated if she were to see any form of abuse she would separate them right away and then tell her charge nurse so it can be investigated. She stated they have been taught not to have their phones on them while working. She stated if she saw a staff member taking video of a resident she would tell them to stop right away and report it to her nurse. On 4/25/23 at 11:52 AM the DON stated all staff are trained on hire and annually regarding abuse, what to do and when to report it. She stated if staff see any form of abuse they are expected to separate the resident to make sure they are safe, report it right away so she can start an investigation and report it to the State Agency within two hours. On 4/25/23 at 1:55 PM when asked the Assistant Administrator, when he became aware of Staff D taking video of Resident #2 he stated he was aware prior to 3/11/23. When informed it was reported that he was informed back in December 2022 or January 2023 he agreed and stated he would check on the date specifically. He stated when Staff E reported it he immediately called Staff D into his office. He stated Staff D denied it and there was no video to prove it so he thought it was teenage drama between the two aides and didn't know if it really happened. He stated they have already done a mini-education with all the aides on phone use. He stated when another staff took pictures of a different resident on 3/11/23 this incident was brought up again so he pulled Staff D back in and she admitted to taking the video. He stated that is when he decided to terminate her. On 4/25/23 at 2:10 PM the Assistant Administrator stated he looked back through his phone and 1/19/23 is when he found out about Staff D taking the video of Resident #2.

Based on clinical record review, facility policy review, family and staff interviews the facility failed to permit a resident to return to the facility after hospitalization and failed to submit notice to the resident or her family of the discharge in writing for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set assessment (MDS) dated [DATE] documented Resident #1 scored 4 on the Brief Interview of Mental Status indicating she is severely cognitively impaired. The MDS documented she required limited assist of one person for transfers, walking, dressing, toileting and hygiene. The MDS documented she was frequently incontinent of urine and occasionally incontinent of bowel. The MDS documented she had diagnoses to include dementia without behaviors, coronary artery disease, hypertension, cerebrovascular accident, and coagulation defect. The MDS documented active discharge planning was not occurring for the resident to return to the community. The MDS documented that no referrals had been made to the Local Contact Agency and that a referral was not needed. The Care Plan dated 9/18/22 documented Resident #1's daughter is her caregiver at home and that she had a hospital stay prior to nursing home placement. The Care Plan documented the resident had settled into placement at the facility. The Care Plan documented the daughter is the decision maker and needs to be included in discussions about her care. The Care Plan lacked documentation of any discharge planning. The undated facility policy Admission Agreement documented the facility shall not involuntarily transfer or discharge the resident, except for medical reasons; for the resident's welfare or the health and safety of other individuals in the facility; for nonpayment of the rates, fees and charges due pursuant to this agreement; by reason of action by the Iowa Department of Human Services; by reason of action by the Professional Standards Review Organization; or if the facility ceases to operate. The facility shall provide the resident with prior notice of transfer or discharge as required by law. The Face Sheet documented the resident admitted to the facility on [DATE]. The contact info documented the daughter as the Power of Attorney for care and emergency contact. The Progress Notes for the resident documented the following: On 4/15/23 at 2:00 PM the resident was admitted to the hospital for observation for syncopal episode. On 4/18/23 at 9:00 AM the resident currently in the hospital. Will see what the discharge orders state on her return. The Progress Notes lacked any documentation of discharge planning, notification of discharge or inability to meet the resident needs. On 4/18/23 at 3:30 PM the Assistant Administrator stated he did not want to take the resident back due to the daughter was not happy with her cares. He stated he had not issued any notice as of now. On 4/18/23 at 3:41 PM during the phone call with the daughter she received a phone call from the hospital and they informed her that the facility just called them and will not accept her back. The daughter stated her mom has only been out of the facility for 3 days and is private pay at the facility. She stated this is the first time she is hearing that the facility does not want to take her back and stated she has never been issued any notice. She stated she has a concern for involuntary discharge. On 4/25/23 at 11:52 AM the Director of Nursing stated it is the policy of the facility to issue notice if they plan on discharging a resident involuntarily.

Based on clinical record review, resident interview, family interview and staff interview the facility failed to provide sufficient staff to answer call lights in a reasonable time and to provide cares every 2 hours for 2 of 6 residents reviewed (Resident #1 and #14). The facility reported a census of 70 residents. Finding include: 1. The Minimum Data Set assessment (MDS) dated [DATE] documented Resident #1 scored 4 on the Brief Interview of Mental Status (BIMS) indicating she was severely cognitively impaired. The MDS documented she required limited assist of one person for transfers, walking, dressing, toileting and hygiene. The MDS documented she was frequently incontinent of urine and occasionally incontinent of bowel. The MDS documented she had diagnoses to include dementia without behaviors, coronary artery disease, hypertension, cerebrovascular accident, and coagulation defect. The Care Plan dated 9/19/22 documented Resident #1 is confused and forgetful. The Care Plan documented she needs reassurance and guidance as to what she is supposed to be doing. The Care Plan documented she is incontinent of urine and wears briefs. The Care Plan directed staff to remind her to use the restroom and to assist her with changing her briefs as needed. The Progress Notes for the resident documented the following: On 3/11/23 at 6:30 AM found resident covered in stool. Resident had dried vomit on the bed and fresh on the floor. Resident taken immediately for a shower. Stool in vaginal vault. On 4/18/23 at 10:45 AM interviewed the Assistant Administrator and Director of Nursing (DON). The DON stated the aide on that hall, Staff D, told her she took Resident #1 to the bathroom at around 11:45 PM and again at 2:00 AM. She stated she was able to confirm with the nurse on duty that night, that she saw Staff D across the hall from Resident #1 around 2:00 AM doing rounds. She could not confirm that she went into that room but she knows 2:00 AM rounds were done and she was in the vicinity of the resident's room. She stated a day aide, came in at 3:30 AM and Staff D left at 3:45 AM. She stated the day aide was unable to get to the resident at 4:00 AM rounds because she ran into problems with some heavy care residents and 4:00 AM rounds ran right into 6:00 AM rounds. She stated the resident was found covered in dried bowel movement (BM) at around 6:30 AM when they went in to do morning cares. The Assistant Administrator stated they staff night shift with one nurse, one aide on south hall, one aide on north hall, one aide in the special care unit and one float. He stated there was a call in that night so they did not have the float but the facility was still sufficiently staffed. The Assistant Administrator stated the aides alerted the nurse due to the condition in which they found the resident. He stated the nurse told them at first she thought it was dried BM and urine that had spread out and that there were different rings indicating more than one episode of incontinence. The DON stated the resident is independent in bed and rolls around to make herself comfortable. She stated she climbs in on her knees and will sleep on her stomach. The Assistant Administrator stated due to 4:00 AM rounds not being done the resident could have been covered in the BM for 4 and 1/2 hours but that it could have been 8 hours if Staff D did not do 2:00 AM rounds. On 4/18/23 at 1:20 PM the aide, Staff A, stated she worked day shift the morning of 3/11/23. She stated she went into Resident #1's room at around 6:30 AM to do morning cares and when she turned on the light she had to do a double take because it looked like the resident had a brown blanket on her. She stated the resident was clothed and was covered in BM from her ankles to her shoulders. She stated it was liquid BM and it was dried to her clothes and skin so it had been there for a while. She stated it appeared she had not been cared for all night. She stated she went and got the nurse because it looked like no one had checked on her all night. She stated another aide helping her, Staff B, stayed and cleaned up the room while she took the resident to shower. She stated that was the only way they were going to get her clean because it was stuck to her. When asked she stated she feels that when the night shift has a call in they do not have enough staff because that is when the staff report to the day shift they are not able to get all the care done. On 4/18/23 at 3:41 PM the daughter stated on 3/11/23 the nurse called her and informed her that her mom was found covered in BM early that morning. She stated they sent her out to the hospital because she almost passed out after being showered. She stated she went to the hospital and the admitting doctor told her she should contact the Ombudsman office to report elderly abuse. The facility showered her to try and clean her up but she was so dirty she still had some on her. She stated the hospital staff had to finish getting her cleaned up. On 4/19/23 at 10:30 AM the nurse, Staff C, stated the morning of 3/11/23 it was obvious the resident did not have any cares throughout the night because the BM was dried to her. She stated the resident could have laid in it for eight hours. On 4/24/23 at 12:49 PM the aide, Staff B, stated on 3/11/23 she went into the resident's room around 6:30 AM with Staff A to get the resident up for the day. She stated they found her asleep on her stomach. She stated it looked like she had brown pajamas on because she had dried feces all over her. She stated it was apparent to her the resident laid in the feces all night because of how dry it was on everything. When asked she stated there is not always enough staff on night shift. She stated when the float is scheduled and shows up it is better but when there are call ins they pull the float and never try to replace them. On 4/25/23 at 8:26 AM the aide, Staff D, stated the morning of 3/11/23 she left work at 3:45 AM. She stated an aide took over for her. She stated that night she did rounds on the resident at midnight and 2:00 AM. On 4/25/23 at 10:42 AM the aide, Staff G, stated the staff have been taught if a resident is unable to toilet or reposition themselves they are to check, change and reposition them every two hours. On 4/25/23 at 11:52 AM the DON stated Resident #1 is independent in bed but she does not know to ask for help so staff are to check and change or toilet her every two hours at night. 2. The MDS dated [DATE] for Resident #14 documented she scored 14 points on the BIMS indicating she was cognitively intact. The MDS documented she required extensive assist of two people for transfers, dressing and toileting. The MDS documented she was frequently incontinent of urine and always incontinent of bowel. The MDS documented she had diagnoses that included heart failure, hypertension, osteoarthritis, and spinal stenosis. The Care Plan dated 12/3/21 documented Resident #14 needs assist with most of her activities of daily living. The Care Plan documented she has had falls, utilizes a sit to stand lift for transfers and uses a call light appropriately. On 4/18/23 at 9:40 AM the resident stated she requires help from the staff getting out of her recliner to her wheelchair and needs help getting onto and off her commode. She stated the staff take good care of her but she is concerned she has to wait for help at times. She stated she has had to wait as long as 30 minutes to an hour for someone to come when she presses her call light. She stated she cannot remember a definite time of day of when it has happened. She stated she knows they are busy and have others to take care of but she stated she has heard staff talk about not having enough staff.

Based on clinical record reviews, staff interviews, and facility policy review the facility failed to submit to the Iowa Department of Inspections and Appeals (DIA) a bruise of unknown origin for 1 of 4 residents (Resident #54) reviewed for accurately reporting reportable allegations to DIA. The facility reported a census of 67 residents. Findings include: 1. The Non-Pressure Skin Condition Report for Resident #54 documented a bruise to the pubis region identified on 8/31/22 measuring 30 centimeters (cm) in width. Record review of an untitled document dated 8/31/22 regarding Resident #54's bruise lacked documentation of how the bruise occurred. The document determined the facility completed interviews with the staff and Resident #54 revealing they did not know how the bruise happened. Record review of Resident #54 Nurses Notes from 8/30/22 to 9/2/22 lacked documentation of how the bruise identified on 8/31/22 occurred. The Facility provided list of Self-Reports submitted to the DIA lacked documentation of notice sent to DIA of Resident #54's bruise found on 8/31/22. On 12/1/22 at 11:02 AM the Director of Nursing confirmed that the facility did not report the bruise to DIA as she did not know it needed to be reported.

Based on clinical record reviews, staff interviews, and facility policy review the facility failed to ensure accurate completion of the Preadmission Screening and Resident Review (PASRR) to include all active reportable diagnoses on the screening for 1 of 1 resident (Resident #61) upon admission to the facility. The facility reported a census of 67 residents. Findings include: Resident #61 ' s PASRR dated 5/7/22 documented the following mental health conditions diagnosed or suspected at the time of the assessment: 1. Post Traumatic Stress Disorder (PTSD), nonspecific somatic disorder Resident #61 ' s admission medical diagnoses documented the following mental health active diagnoses upon admission to the facility on [DATE]. 1. Neurocognitive Disorder with Lewy Bodies 2. Parkinson's disease 3. Attention-Deficit Hyperactivity Disorder, Unspecified Type 3. Post-Traumatic Stress Disorder, Chronic 4. Bipolar Disorder, Current Episode Manic without Psychotic Features, Moderate 5. Hallucinations, unspecified 6. Insomnia, Unspecified 7. Bipolar Disorder, Unspecified On 12/1/22 at 12:03 AM the Director of Nursing reported that she does not ensure all diagnoses are reflected on the PASRR prior to the resident ' s admission to the facility. The surveyor ' s requested the PASRR policy, but the facility did not provide one during the survey.

Based on observations, clinical record reviews, staff, and resident interviews the facility failed to initiate a new order that changed the frequency of completion of wound care for 1 out of 3 residents reviewed (Resident #271). The facility reported a census of 67. Findings include: Resident #271's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS indicated that Resident #271 had one surgical incision that required wound care. The MDS indicated an admitted [DATE] from an acute hospital. Resident #271 required total assistance of two persons with transfers. The MDS indicated Resident #271's primary admission diagnosis of a non-pressure chronic ulcer of the other part of the left foot with a fat layer exposed. The Care Plan dated 11/25/22 revealed the resident admitted to the facility on a skilled level of care for a postoperative wound to his left foot. On 11/29/22 at 8:28 AM Resident #271 stated he had a really big ulcer on his left foot, about the size of a golf ball. He didn't know how it happened. He had three surgeries on it before coming to the facility for more care. The staff changed the dressing once everyday. On 11/29/22 at 11:30 AM Staff B, Registered Nurse (RN), stated that she checked the Treatment Administration Record (TAR) and the dressing is changed every day on day shift. Usually it is changed in the morning but today is his bath day so it will be changed in the afternoon after his bath. The MD/Nursing Communication form signed and noted on 11/22/22 had a handwritten order to continue to change the dressing every other day with silver alginate. On 11/30/22 at 10:10 AM observed Staff A, Licensed Practical Nurse (LPN), do the dressing change to Resident #271's left foot. The dressing Staff A removed included a date of 11/29/22. Resident #271's November 2022 TAR directed the staff to change the dressing to his wound daily. On 11/30/22 at 10:33 AM the Director of Nursing (DON) revealed after reviewing the order and TAR, that she didn't know that the TAR had different orders on the chart for frequency of doing the dressing change. On 11/30/22 at 10:40 AM the DON stated she talked to the nurse who noted the order. The nurse thought the order was already for every other day when she noted it. The DON reported that they would contact the doctor for clarification.

Based on observations, staff interviews, and clinical record reviews the facility failed to keep a catheter bag off of the floor when the resident was in bed for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 67 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS indicated that Resident #3 required total assistance of two persons with bed mobility, transfers, and toilet use. The MDS included that Resident #3 received hospice services. The MDS indicated that Resident #3 had an indwelling catheter and colostomy. Resident #3's MDS included diagnoses of Non-Alzheimer's dementia, psychotic disorder, hypertension, peripheral vascular disease (PVD), neurogenic bladder, diabetes mellitus, and history of novel Coronavirus 2019 (COVID). On 11/29/22 at 9:17 a.m. observed Resident #3's urinary catheter drainage bag with a dignity cover hanging on the end of the bed touching the floor. On 11/30/22 at 3:00 p.m. observed Resident #3's catheter bag with a dignity cover laying on the floor underneath the bed. The Care Plan Focus revised 5/13/22 indicated that Resident #3 had cognitive loss with behavioral symptoms. Resident #3 would repeatedly ask to use the bathroom or go to bed. The included intervention dated 2/4/19 indicated that Resident #3 had a neurogenic bladder and required an indwelling catheter. The intervention continued instructing staff to monitor for increased confusion due to a history of urinary tract infections (UTIs). The Care Plan Focus revised 1/12/22 listed that Resident #3 had a decline in activities of daily living (ADL) status. She needed assistance with ADL's. The focus included an intervention revised 10/20/21 that Resident #3 had a history of UTIs that required urologist intervention with recommendations to change her urinary catheter every thirty days. A Physician Order dated 10/10/22 documented Resident #3's indwelling urinary catheter be changed monthly due to her diagnosis of Neurogenic Bladder. An undated facility policy titled Catheter Care directed staff to position the resident so that the catheter and tubing are free of kinks and pulling. The policy also stated to be sure drainage or tubing never touches the floor. During an interview on 12/1/22 at 11:05 a.m. the Director of Nursing reported that a resident's catheter drainage bag should not be touching the floor.

Based on clinical record reviews, observations, and staff interviews, the facility failed to provide oxygen according as the physician orders for 1 of 1 resident (Residents #8) reviewed for respiratory services. The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) for Resident #8 dated 11/20/22 documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #8 required oxygen while a resident at the facility. Resident #8's MDS included diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD), heart failure, renal disease, diabetes mellitus, depression, morbid obesity, obstructive sleep apnea, pulmonary hypertension due to lung disease and hypoxia. On 11/30/22 at 3:00 p.m. observed Resident #8's lying in bed wearing oxygen set at 3 liters per nasal cannula (L/NC). On 12/1/22 at 7:30 a.m. observed Resident #8 sitting in his recliner wearing oxygen set at 3 L/NC. The Care Plan Focus revised 6/15/22 indicated that Resident #8 returned to the facility after attempting to go home. Resident #8 could be independent throughout the facility if he had his portable oxygen with him. The undated intervention instructed staff to administer oxygen (O2) at 2 L/NC at night and as needed for comfort. A Physician Order dated 6/16/22 directed staff to administer oxygen at 2 L/NC routinely at night and as needed (PRN) during the day. Review of Resident #8's Nurses Notes revealed the following documentation the facility did not have physician orders to administer: a. 9/4/22 at 2:00 PM - The Registered Nurse (RN) gave as needed (PRN) morphine at 6:35 AM for complaints of shortness of breath. The administration worked effectively per Resident #8, he had an O2 saturation of 93% on 3 L/NC. b. 9/30/22 at 12:00 PM - Resident #8 complained of shortness of breath. He received Roxanol and albuterol nebulizer at 9:00 AM with his scheduled Roxanol and duoneb given at 10:45 AM. O2 saturation at 91% on 3L/NC. c. 10/1/22 at 9:00 AM - Follow-up vitals signs after a fall revealed an O2 saturation of 92% on 3 L/NC. d. 10/3/22 without a time - Resident #8 had an O2 saturation of 93% on 4 L/NC. e. 10/8/22 at 8:00 AM - Resident #8 had O2 increased to 5 L/NC, the nurse turned the O2 down to 2L/NC. An undated facility policy directed staff to administer oxygen when the resident is showing signs of shortness of breath and/or pulse oximetry lower than 90% or as otherwise ordered by the physician. During an interview on 12/1/22 at 9:00 a.m. the Director of Nursing (DON) reported that she would expect the staff to follow the physician's order for oxygen services.

Based on clinical record reviews, staff interviews, and facility policy review the facility failed to report an attempted suicide to Iowa Department of Inspections and Appeals (DIA) for 1 of 1 residents reviewed (Residents #32). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) for Resident #32 dated 10/8/22 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS identified Resident #32 required assistance of one person with walking and transfers. Resident #32 MDS included diagnoses of non-Alzheimer's dementia, depression, cerebrovascular disease, and hypothyroidism. The Incident/Accident Report dated 9/7/22 documented that Resident #32 attempted suicide by wrapping a phone cord around her neck. Record review of a undated document titled Self Reports to the Iowa Department of Inspections and Appeals (DIA) for the facility lacked documentation of a report of Resident #32 suicide attempt on 9/7/22. During an interview on 11/30/22 at 3:26 p.m. the Director of Nursing (DON) verified the facility did not report the suicide attempt to the DIA. The DON reported she did not know that a suicide attempt needed to be reported to DIA. A undated facility policy on Self Reports to DIA directed staff to report a suicide attempt regardless of injury to DIA.

Based on observations. clinical record review and interviews the facility failed to develop and implement a comprehensive Care Plan for 2 of 16 residents reviewed (Resident #7 & #36). The facility reported a census of 62 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severely impaired cognition. The MDS documented she required limited assistance of 1 staff for bed mobility, transfers, walking in and out of room, dressing, toilet use, and personal hygiene. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's Care Plan updated 3/3/21 lacked information for her pressure injury to the right ear, or any interventions to prevent further skin breakdown. The Care Plan also lacked information about her [CONDITION(S)] (swelling)and the use of unna boot or interventions to help lessen the [CONDITION(S)] in her lower extremities. The document Weekly Pressure Injury Record dated 3/31/21 included a Stage II (Partial thickness loss of skin loss with exposed dermis. The wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister. Granulation tissue, slough and eschar are not present) Pressure ulcer to her right ear lobe that measured 0.4 centimeters (cm) by 0.3 cm with a depth of 0.2 cm. Resident #7's Treatment Administration Record (TAR) included Cleanse area to right outer ear, apply Duoderm (dressing) change on bath days until resolved, with a start date of 3/31/21. Unna boots to bilateral lower extremities, change on bath days. Okay to cover with Coban with a start date of 4/22/21. An observation on 5/24/21 at 1:09 PM Staff B License Piratical Nurse (LPN) preformed hand hygiene and donned gloves, obtained disinfectant wipes and cleaned over bed table. Staff B doffed gloves used hand sanitizer and donned gloves pulled out treatment items and placed and towel on the table. Placed on top of towel wound cleanser scissors, gauze and Duoderm. Doffed gloves and used hand sanitizer and donned gloves opened packages and placed on table sprayed gauze with wound cleaner and dried. Doffed gloves and used hand sanitizer and donned gloves. Wiped area with skin prep and placed the Duoderm on top. Picked up items and doffed gloves and used hand sanitizer. Staff B used hand sanitizer donned gloves pulled up pants and found out resident did not have her shower yet. CNA checking on it. An observation on 5/24/21 at 2:31 PM Staff B LPN washed hands placed towel on the floor and supplies on top unna boots and coban, gloves and hand sanitizer and washed hands and donned gloves opened unna boots doffed gloves and used hand sanitizer. Donned gloves started at the base of foot right above toes wrapped up to just below the knee and back down then wrapped with coban. Doffed gloves used hand sanitizer and donned gloves. Wrapped the unna boot up to just below the knee on the left leg and back down. Doffed gloves used hand sanitizer and put the coban on over the unna boot. Then attached the lower leg bag strap and pulled down her pant legs. and placed the gripper socks on. Picked up items and used hand sanitizer. Place Residents legs up. 2. The quarterly MDS assessment dated [DATE] revealed Resident #36 displayed intact cognitive abilities. The MDS documented she required extensive assistance of 2 staff for bed mobility and dressing, total assist of 2 staff for transfers and toilet use, and limited assist of 1 staff for personal hygiene. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident had no Restorative Nursing Program (RNP) performed during seven of seven days during the assessment reference period. Resident #36's Care Plan updated 4/14/21 lacked any information for her restorative program. The Restorative Nursing Recommendations signed by the therapist on 1/11/21 included upper extremities exercises 2 to 10 with either 2# weight or yellow Thera band seated at the edge of the bed to be done 3 to 5 times a week. The Restorative Nursing Recommendations signed by the therapist on 4/10/21 included goal to increase and maintain core and lower extremities strength and Range of Motion (ROM) to progress to EZ stand transfers weight bearing of right lower extremities progresses. Additional instruction complete as tolerated 3 to 6 times a week. No resistance for right lower extremity, active movement to active assistive and to see types exercises attached as follows. Restorative Exercises - Resident #36 1. In bed or recliner - use leg lifter to pull foot into dorsiflexion hold 20 -30 seconds. Repeat 3 times each foot, 2. Sit on edge of bed and balance - can work on reaching for cones. 5 plus minutes. 3. Sit on edge of bed, lift (L) foot forward/back, side to side & may use tape as target. Do 8-10 times (L) leg. 4. Sitting on edge of bed, (do all exercise slow and controlled) 8 - 12 times. a. Try to straighten left knee (place washcloth under foot to help slid on floor) b. Pull foot back c. March in place 5. Lay in bed (ok to have head up to view legs) 8 to 12 reps each Left Leg a. AAROM (Assisted Active Range of Motion) to AROM (Active ROM) hip /knee flexion/extension. b. AAROM to AROM - hip abduction/adduction -knee pointed at ceiling c. AAROM/AROM - straight leg raise right leg d. AAROM to AROM -hip/knee flexion/extension e. AAROM to AROM - hip abduction/adduction - knee pointed at ceiling f. AAROM/AROM -straight leg raise g. Both Ankles - PROM (Passive Range of Motion)- 3 reps During an interview on 5/25/21 at 3:21 PM with the Director of Nursing (DON) explained she would expect the pressure ulcer to be on the care plan for Resident #7 and acknowledged she understood how things got missed Resident #36 since we have done so much with her. The nurses had been down with her all the time. The DON states she could see how things would get missed on her Care Plan.

Based on observation, clinical record review, and staff interviews, the facility failed to ensure staff properly primed an insulin flex pen prior to administering the dose as directed for 1 of 1 residents reviewed (Resident #10). The facility identified a census of 62 residents. Findings include: The quarterly MDS dated [DATE] revealed Resident #10 received insulin injections 7 out of 7 days during the look back period. Resident #10's Order Summary Report dated 5/25/21 included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 0-175 =0 units 176-225 = 4 units 226-275=8 units 276-325=12 units 326-375=16 units 376-425=20 units If blood sugar exceeds 425, call doctor. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Guide to Using Your Novolog [MEDICATION(S)] insert directed: a. Remove the cap. Pull off the pen cam and wipe the rubber stopper with and alcohol swab. b. Attach new needle and remove paper tab, push and twist needle on until tight. Remove both needle caps. c. Prime. Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. d. Select your dose. Turn the dose selector to select the number of units needed. e. Give injection: Insert needle, press and hold dose button. After dose counter reaches 0, slowly count to 6. f. After injection, carefully remove needle and put in sharps container. Put the pen cap back on the [MEDICATION(S)]. Observation on 5/24/21 at 11:34 AM revealed Staff D wiped the end of Resident #10's [MEDICATION(S)] with alcohol, placed the needle on the pen and dialed up 8 units for the sliding according to the sliding scale order. As Staff D went to inject the insulin, the surveyor stopped Staff D to prime the [MEDICATION(S)] before giving the dose. During an interview on 5/25/21 at 2:49 PM, the Director of Nursing stated she would expect the nurse to follow manufacturers instructions and prime the pen if it is required. In a subsequent interview on 5/26/21 at 9:05 AM, the DON reported Staff D acknowledged she did not prime the insulin pen prior to going to administer the insulin.

Based on clinical record review, resident and staff interviews the facility failed to provide consistent restorative program to maintain, restore or improve the function ability for 1 of 1 Resident reviewed (Resident # 36) with a restorative program. The facility report a census of 62 Residents. Findings include: The quarterly MDS assessment dated [DATE] revealed Resident #36 displayed intact cognitive abilities. The MDS documented she required extensive assistance of 2 staff for bed mobility and dressing, total assist of 2 staff for transfers and toilet use, and limited assist of 1 staff for personal hygiene. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident had no Restorative Nursing Program (RNP) performed during seven of seven days during the assessment reference period. Resident #36's Care Plan dated 12/23/20 included Activity of Daily Living ADL's issues related to the bilateral femur fractures in September of 20. As of 12/23/21 the left femur is healed but still not able to put any weight on the right leg. The Resident needs to bear weight with the EZ stand (mechanical lift to help stand) before able to go home. The Restorative Nursing Recommendations signed by the therapist on 1/11/21 included upper extremities exercises 2 to 10 with either 2# weight or yellow Thera band seated at the edge of the bed to be done 3 to 5 times a week. The Restorative Nursing Recommendations signed by the therapist on 4/10/21 included goal to increase and maintain core and lower extremities strength and Range of Motion (ROM) to progress to EZ stand transfers weight bearing of right lower extremities progresses. Additional instruction complete as tolerated 3 to 6 times a week. No resistance for right lower extremity, active movement to active assistive and to see types exercises attached as follows. Restorative Exercises - Resident #36 1. In bed or recliner - use leg lifter to pull foot into dorsiflexion hold 20 -30 seconds. Repeat 3 times each foot, 2. Sit on edge of bed and balance - can work on reaching for cones. 5 plus minutes. 3. Sit on edge of bed, lift (L) foot forward/back, side to side & may use tape as target. Do 8-10 times (L) leg. 4. Sitting on edge of bed, (do all exercise slow and controlled) 8 - 12 times. a. Try to straighten left knee (place washcloth under foot to help slid on floor) b. Pull foot back c. March in place 5. Lay in bed (ok to have head up to view legs) 8 to 12 reps each Left Leg a. AAROM (Assisted Active Range of Motion) to AROM (Active ROM) hip /knee flexion/extension. b. AAROM to AROM - hip abduction/adduction -knee pointed at ceiling c. AAROM/AROM - straight leg raise right leg d. AAROM to AROM -hip/knee flexion/extension e. AAROM to AROM - hip abduction/adduction - knee pointed at ceiling f. AAROM/AROM -straight leg raise g. Both Ankles - PROM (Passive Range of Motion)- 3 reps Documentation related to the resident's Restorative Programs documented a ROM Goal: Resident #36 will participate in exercises 3-6 times per week as desired. January 2021: week 1 = 6 times, week 2 = 6 times, week 3 = 3 times, week 4 = 3 times February 2021: week 1 = 3 times, week 2 = 4 times, week 3 = 5 times, week 4 = 4 times March 2021: week 1 = 5 days, week 2 = 3 times, week 3 = 3 times, week 4 = 5 times, week 5 = 3 times every day April 2021: week 1 = 1 day, week 2 = completed 1 day, offered and refused 1 day, week 3 = 2 days, refused 1 day week 4 = 3 days, refused 2 days May 2021: week 1 = 2 days, week 2 = 4 days, week 3 = 1 day During an interview on 5/24/21 at 8:38 AM, Resident # 36 verified she had therapy and is on a restorative program. She added that she does not always have it when she is supposed to because the staff sometimes get pulled to the floor to work as a Certified Nursing Aide (CNA) and is not able to do both during her shift. In an interview on 5/25/21 at 1:27 PM, Staff G CNA/RA (Restorative Aide) reported she is the first person pulled to the floor when someone calls in sick and Resident #36 missed a lot of restorative treatments as a results. Staff G reported this upset the resident, but she not blame Resident #36 for getting upset she missed restorative. She added that is why they mark her calendar when we do restorative.

Based on observations, clinical record review, and staff interviews, the facility failed to ensure staff evaluated and documented a reason to explain the continued use of an 'as needed' (PRN) [CONDITION(S)] medication beyond 14 days for 1 of 5 residents reviewed (Resident #4). The facility also failed to provide an end date for a PRN [CONDITION(S)] medication for 2 of 2 residents reviewed (Residents #4 & #62). The facility reported a census of 61 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 2/20/21, Resident #4 had diagnoses that included dementia with behavioral disturbance, [CONDITION(S)] (BPH), diabetes; non-Alzheimer's dementia; [CONDITION(S)], and [CONDITION(S)]. The MDS documented Resident #4 demonstrated moderate cognitive impairment with poor daily decision-making skills and displayed physical, verbal behavioral symptoms toward others and other behavioral symptoms not directed toward others during the MDS lookback period. The MDS also documented the resident as independent with bed mobility and surface-to-surface transfers but required assist of 1 staff with eating and assist of 2 staff with toilet use. The MDS revealed Resident #4 experienced both bowel and bladder incontinence and had 6 falls. The MDS also revealed the resident took an anti-psychotic medication on 5 of 7 days and an anti-anxiety medication on 7 days during the MDS lookback period. A facility document titled Physician's telephone orders audit dated 2/9/21-5/20/21 revealed: a. 2/9/21 order for [MEDICATION(S)] 0.5 mg 1 by mouth every 4 hours PRN agitation x 14 days (order end date 2/23/21) b. Lack of physician order for PRN [MEDICATION(S)] with date 2/24/21-3/8/21 c. 3/9/21 order for [MEDICATION(S)] 0.5 mg x 14 days (order end date 3/23/21) d. Lack of physician order for PRN [MEDICATION(S)] with date 3/24-4/5/21 e. 4/6/21 order for PRN [MEDICATION(S)] x14 days (order end date 4/20/21) f. 4/20/21 order for PRN [MEDICATION(S)] x14 days for anxiety/restlessness/agitation (order end date 5/4/21) g. 4/29/21 order for continued PRN [MEDICATION(S)] (order without an end date) h. 5/3/21 order for PRN [MEDICATION(S)] x14 days (order end date 5/17/21) i. 5/6/21 order for PRN [MEDICATION(S)] x 2 weeks (order end date 5/20/21) j. 5/20/21 order to renew [MEDICATION(S)] (order without an end date) Review of the Progress Notes dated 2/23/21 -5/18/21 revealed a lack of documentation in the medical record for Resident #4 to have an extended order with rationale beyond 14 days of PRN [CONDITION(S)] medication and evaluation for the appropriate use of the medication: a. Lack of facility evaluation of PRN effectiveness documentation of 4/20/21 order. b. Lack of facility evaluation of PRN effectiveness documentation of 4/29/21 order. c. Lack of facility evaluation of PRN effectiveness documentation of 5/3/21 order. d. Lack of facility evaluation of PRN effectiveness documentation of 5/6/21 order. On 5/25/21 at 10:10 a.m., the Director of Nursing (DON) stated there is a facility gap in their processes with physicians completing required documentation with as needed (PRN) [CONDITION(S)] medication evaluations when a resident has a need beyond the 14 day order. In a subsequent interview on 5/26/21 at 10:11 a.m., the DON explained that when a nurse administers a controlled medication, he or she is supposed to document on the Medication Administration Record, the Controlled Drug Receipt Form, and the PRN Medication Record.

Based on observation, record review, and staff interview the facility failed to ensure staff washed their hands and changed their gloves in accordance with standard infection protocols for one of three residents observed (Resident #1). The facility census was 63 residents. According to the Minimum Data Set (MDS) assessment tool dated 6/19/20, Resident #1's had [DIAGNOSES REDACTED]. The MDS documented the resident displayed moderately impaired cognition and required assistance of one staff for bed mobility, transfers, and toilet use. The MDS revealed the resident exhibited both bowel and bladder incontinence. During an observation on 6/24/20 at 9:30 20 AM, Staff A, certified nursing assistant (C.N.A.), assisted Resident #1 to the restroom and told him to place his call light on when he was finished. When Resident #1 activated his call light, Staff A, Certified Nursing Assistant (CNA) knocked on the door, sanitized her hands, entered the room and knocked on the resident's bathroom door. Staff asked the resident if he was finished and Resident #12 replied yes. Staff A, donned gloves, assisted the resident to stand, cleansed the resident's bottom with wipes. Staff A then dispensed into the palm of their hand while still wearing a soiled glove and proceeded to rubbed the on the resident's bottom. Staff A removed their gloves, sanitized their hands, pulled up the resident's pants, assisted him back to his chair, gave resident his call light, opened his window and then washed their hands and left the room. In an interview conducted on 6/24/20 at 10:00 AM the DON verified after perineal care, staff should remove their gloves, wash their hands, and don new gloves prior to applying lotion to a resident's clean skin.

Based on clinical record review, observation, and staff interview, the facility failed to secure cigarettes and lighters for 6 residents that smoked cigarettes (Resident #18, #41, #42, #51, #64, & #115). The facility reported a census of 69 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented Resident #18 had [DIAGNOSES REDACTED]. The MDS documented a score of 9 out of 15 on the Brief Interview Mental Status indicating moderate cognition. The MDS documented the resident as independent with walking. Observation on 6/9/19 at 1:23 pm revealed 2 packs of cigarettes and 2 lighters sat unsecured at the north nurse's station. At 1:30 p.m., nursing staff secured the items in the medication cart Observation on 6/10/19 at 8:45 am showed 2 packs of cigarettes and 2 lighters sat unsecured at north nurse's station. Nursing staff secured the cigarettes and lighter in the medication cart at 9:19 am. At 9:30 am, Resident #18 approached the north nurse's station in search of his cigarettes and lighter. The resident stated he keeps his cigarettes and lighter right at the nurse's station so he can smoke whenever he wants. During an interview on 6/12/19 at 7:00 am. the director of nursing stated the above 6 smokers have been deemed as safe smokers and could smoke without supervision, however, the director of nursing acknowledged the importantance of securing the cigarettes and lighters.

Based on clinical record review, observation, and resident interview, the facility failed to knock and wait for permission to enter a resident's room (Resident #18 & #51). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documented Resident #18 had [DIAGNOSES REDACTED]. The MDS documented a score of 9 out of 15 on the Brief Interview Mental Status indicating moderate cognitive impairment. During observation on 6/10/19 at 1:47 pm while conducting the resident interview, staff walked into the resident's room without knocking or waiting for permission to enter. The resident reported it happened all the time. The resident added this bothers him because he would like his privacy. 2. The MDS dated [DATE] documented Resident # 51 had [DIAGNOSES REDACTED]. The MDS documented the resident as fully dependent on staff for toilet use. During observation on 6/11/19 at 6:52 am Staff C and Staff D, both certified nursing assistants had covered the resident's torso with a towel. Staff C removed the towel and left the resident exposed while gathering supplies until 6:56 a.m. After completing incontinent cares at 7:03 am, staff left the resident exposed for 2 more minutes while staff washed their hands. Observation on 6/11/19 at 3:32 pm, revealed Staff [NAME] and the director of nursing changed the dressing on the resident's foot. At 4:19 p.m., Staff B, registered nurse, knocked while entering the room and did not wait for permission to enter.

Based on observation, clinical record review and staff interviews, the facility failed to consistently use gait belts when indicated for resident safety for 1 of 8 residents reviewed with recent falls ( Resident #1). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #1 had [DIAGNOSES REDACTED]. The resident had short and long term memory impairment and severely impaired cognitive function. The MDS identified the resident required limited staff assistance with bed mobility, transfers, ambulation both in and out of the resident's room. The MDS coded the resident's balance as steady at all times during transitions and ambulation and no impairments with functional limitation in range of motion in either the upper or lower extremities. A care plan review conducted on 11/20/13, indicated the resident as an elopement risk and required placement in the special care unit. The care plan identified the resident as at risk for falling due to confusion daily, eye problems making it hard to see and blindness in the left eye. Interventions directed staff to ensure gripper strips in front of bed, pressure alarm on after 7:00 p.m. and in bed at all times, routine toileting schedule, wear hipster underpants at night, keep bathroom light on at all times, keep night stand at the foot of the bed, attempt the lowest doses possible for anxiety medication, monitor for complaints of pain and monitor and report any changes in gait. A Fall Risk Assessment completed on 10/1/13, 11/4/13, 11/23/13, and 1/24/14 identified the resident at risk for falls due to confusion, impaired judgement/decision making skills, anxiety, macular degeneration with blindness of the left eye, mild hearing loss, receiving 3 or more medications and some occasional urinary dribbling. An Accident/Incident form completed on 10/1/13 at 7:00 p.m., documented staff found the resident seated on the floor beside the bed unable to verbalize to staff what happened. The resident wore gripper socks at the time of the incident and denied any injury. The care plan intervention following the fall included a pressure alarm on at all times after supper. The certified nurse aide, CNA Kardex noted the addition of the new intervention. An Accident/Incident form completed on 11/23/13 at 8:45 a.m., revealed the resident was found on the floor in the door way from the living room area going out into the hallway. The assessment revealed no apparent injuries and the immediate intervention put in place directed staff to ensure the resident wore hipster pants at all times. An Accident/Incident form completed on 11/26/13 at 9:00 p.m., revealed the resident was ambulating without assistance as the nurse entered the resident's room. The resident lost balance and the nurse could not reach the resident in time to prevent the fall. Neither the incident form or the nursing note documentation indicated if staff applied the pressure pad alarm as directed by the care plan or if it sounded. The immediate care plan intervention added after the fall directed the staff to ensure the resident wore gripper socks while in bed. An Accident/Incident Report completed on 2/9/14 at 8:30 p.m., revealed the resident was ambulating with staff when the resident let go of staff's hand, lost balance and fell to the floor hitting head. The resident sustained [REDACTED]. The nurse applied ice and administered a pain pill for resident comfort. The resident's spouse did not desire the resident be transferred to a local hospital for evaluation following the fall and the physician on call agreed to go along with the family's wishes. Nurse notes dated 2/9/14 at 10:30 p.m., documented resident ambulating with staff and left go of staff's hand, lost balance and started to fall. Staff tried to grab for resident but was unsuccessful. resident fell to floor onto left side. Resident hit head on floor in hallway. The resident was assessed and physician and family notified. Nurse notes dated 2/9/14 at 12:00 a.m., documented the resident had hip swelling and an abnormal gait and was sent to the emergency room for evaluation. Nurse notes dated 2/10/14 at 3:15 a.m., the resident returned to the facility from the emergency room . No acute fracture but subdural hematoma noted. A Non-contrast Head Scan report dated 2/10/14 at 12:43 a.m., revealed the resident sustained [REDACTED]. Care plan interventions dated 2/9/14, directed to assist the resident with 2 staff present for all ambulation, transfers, dressing and toileting needs and pressure alarm after supper and when in bed at all times. The facility policy for Use of Gaitbelt dated 1/5/07, indicated as its Purpose: " The gaitbelt is intended for use when lifting, ambulating or transferring residents. It is not to be used as a safety restraint in any chair, wheelchair, or bed. All nurse aides are expected to wear and use a gait belt. All residents that require more than standby assistance will have a gait belt issued to them unless specifications in their care plan." During interview on 3/5/14 at 10:10 a.m., Staff A, CNA revealed the capacity of the SCU as eight residents. Staff A explained the normal staffing for the unit included 2 CNAs on the day shift ( 6:00 a.m. to 2:30 p.m.) 2 CNAs for the evening shift though one generally left after 8:00 p.m. the other stayed until 11:00 p.m. and one CNA for the night shift. Staff A explained the nurse from the south wing also covered the SCU unit. Staff A verified she had cared for Resident #1 and explained the resident required assistance with all personal cares. Staff A explained the resident did not have a good sense of reality and talked non-sense but at times could let the staff know basic needs. Staff A stated Resident #1's gait appeared steady and ambulated on the unit independently during the day but did recall the use of an alarm in bed due to the resident's poor vision especially at night. Staff A described the resident as sweet natured but occasionally cranky, delusional and restless at times. Staff A stated the resident had difficulty concentrating on things so staff did more 1 to 1 activities with better results. Staff A explained the facility's policy regarding the use of gaitbelts. Staff A stated any resident with an alarm required the use of a gaitbelt for transfers and ambulation. Staff A stated she knew the location of the gaitbelt policy and stated the facility reviewed the policy periodically at inservice education programs. Staff A explained the charge nurse for the unit was not in the unit expect a couple of times during the shift to pass medications. Staff A explained if she needed the nurse or needed more CNA assistance, she just pressed a beeper/pager that alarmed out on the floors letting other staff know she needed assistance in the SCU. Staff A stated depending upon how she activated the alarm determined how quickly staff responded. Staff A stated if she pressed the alarm several times in a row, staff knew she needed assistance immediately. Staff A stated if a resident fell in the unit, she ensured their comfort and summoned the buzzer to get more assistance. Staff A stated she never moved a resident after a fall and waited for the charge nurse to come back to the unit to assess the resident. Staff A stated prior to Resident #1's fall, the resident often held onto staff's hand when ambulating. Staff A stated once they applied the alarm after supper, they needed to use a gaitbelt when assisting the resident as the resident was no longer viewed as independent with transfers and ambulation. During interview on 3/5/14 at 10:20 a.m., Staff B, CNA stated stated several of the residents in the unit required the use of alarms and on the evening shift especially, the residents tended to become more restless as many of the residents remained quite mobile. Staff B explained the nurse covering the unit generally came back to the unit at least twice during the shift to pass medication but she could use the buzzer to summon the nurse as needed. Staff B verified she worked with Resident #1 and described the resident as pleasant, ambulated with a steady gait, became irritated at times , could not see well but wanted to remain independent with most things. Staff B stated Resident #1 required total staff assistance with all activities of daily living but ambulated independently on the unit during the day shift. Staff B stated when Resident #1 became more frustrated or irritable she noted his/her gait became more unsteady and the resident tended to stumble. Staff B stated she did not use a gait belt to ambulate the resident on the day shift prior to the fall on 2/9/14. When asked when Staff B would use a gaitbelt, Staff B replied if the resident appeared unsteady with ambulation or tended to lean forward or to a particular side, if a resident did not feel well or appeared weak and unable to safely walk unassisted. Staff B stated currently Resident #1 required the use of a PSA and pressure pad alarm at all times. Staff B stated all staff used a gaitbelt now to assist the resident. Staff B felt the resident's condition had been steadily declining prior to the fall on 2/9/14 and expressed concern regarding the resident's poor vision. During interview on 3/5/14 at 10:45 a.m., Staff C, licensed practical nurse, LPN revealed she often worked as the South Hall charge nurse and passed medications to the residents in the SCU. Staff C explained if staff in the unit needed her or needed additional assistance, they pushed a buzzer that could be heard throughout the facility. Staff C stated she cared for Resident #1 prior to the fall and described the resident as independent with mobility on the day shift, pleasantly confused but never combative, restless, and needed staff assistance for activities of daily living. Staff C stated she did not use a gaitbelt with the resident during the day shift but recalled the resident used an alarm after supper. Staff C stated Resident #1 often held onto the staff's hand while walking in the unit. Staff C stated since the fall on 2/9/14, Resident #1 required 2 staff assistance for all cares, had alarms at all times and a gaitbelt was used for all transfers and ambulation. Staff C stated since the fall on 2/9/14, she did not feel Resident #1 showed any decline in condition or function. When asked when she expected staff to use a gaitbelt on a resident she stated if a resident demonstrated unsteadiness, if care planned to receive staff assistance with transfers and ambulation and if identified as a fall risk and required the use of alarms for safety. During interview on 3/5/14 at 1:30 p.m., Staff D, CNA, explained Resident #1 ambulated on the unit independently prior to the fall on 2/9/14 during the day shift. Staff D stated staff applied an alarm after supper until morning due to the fact the resident's balance seemed to get worse by the evening, became more restless, and did not see as well at night. Staff D stated once alarmed staff assisted the resident with ambulation and used a gaitbelt. When asked when she used a gaitbelt she replied anyone who needed assistance with ambulation required the use of a gaitbelt. During interview on 3/5/14 at 1:50 p.m., Staff E, CNA, explained a normal evening shift for Resident #1 included snacks and coffee mid afternoon with the resident's spouse, had supper and then got ready for bed. Staff E explained the resident required the application of an alarm ( chair/bed) after supper following medication pass and through the night due to being identified as a fall risk and the tendency to get up out of bed independently throughout the evening and night shifts. Staff E explained the resident tended to move quickly and did not see well especially at night. Staff E explained Resident #1 could have episodes of not sleeping for 24 - 36 hours consecutively. Staff E stated she never used a gaitbelt on Resident #1 once she applied the alarm after supper. Staff E stated she did not know until she re-read the care plan and CNA kardex after the fall on 2/9/14 that she needed to use a gaitbelt to assist the resident after alarmed as the resident no longer fit the criteria for being independent with transfers or ambulation. Staff E explained on 2/9/14, Staff F, LPN came back to the unit around 8:00 - 8:30 p.m. to administer eye drops to Resident #1. Staff E stated after Staff F left, she heard Resident #1 rustling in bed so went to the resident's room to check and attempted to calm the resident down and encouraged the resident to lay back down and go back to sleep. Staff E stated while attempting to encourage Resident #1 to go back to sleep, she awakened Resident #2 who also became restless. Staff E explained Resident #2 usually walked around the unit in the merry-walker when restless as this appeared to be calming. Staff E stated earlier in the shift, she placed the merry-walker in the shower room. Staff E stated she assisted Resident #1 out of bed without the use of a gaitbelt and then assisted Resident #2 out of bed without the use of a gaitbelt and decided since she could not leave either resident in the room unattended, she would hold each resident's hand and walk with them down the hall to the shower room to get the merry-walker for Resident #2. Staff E stated prior to leaving the room with both residents, she did think about using her buzzer/pager to call for additional assistance as by this time the other CNA had left for the evening. Staff E stated she did not because she felt she could manage both of the residents ambulating the short distance to the shower room. Staff E stated Resident #2 held her hand but also held onto the handrail in the hallway and Resident #1 just held onto her hand. Staff E stated just before arriving to the shower room door, Resident #1 let go of her hand, partially turned, lost his/her balance, and fell to the floor landing hard onto the left side. Staff E stated Resident #1 fell away from her so she could not attempt to break the fall. Staff E stated Resident #1 hit the left side of the head on the floor. Staff E stated her intention had been to place Resident #1 on the toilet once in the shower room while assisting Resident #2 into the merry-walker. Staff E stated she immediately hit her pager and several staff came to assist her. Staff E stated she reported to the charge nurse what happened and the nurse immediately assessed the resident for injuries. When asked about gaitbelt use Staff E replied she needed to use a gaitbelt for any resident who had alarms or needed assistance with transfers and ambulation. Staff E stated she had difficulty making the connection that once Resident #1 had the alarm applied he/she no longer could transfer or ambulate independently. Staff E stated the Kardex information pertaining to the residents was readily available and accessible to her but she stated she did not interpret the information correctly and accepted full responsibility for that. Staff E stated she took full responsibility for not using a gaitbelt on either resident as directed by the care plan. Staff E stated she had to make a judgement call at the time and did so with the thought of how she could keep both residents safe at the time. During interview on 3/5/14 at 2:25 p.m., Staff F, LPN, verified she had administered eye drops to Resident #1 around 8:00 - 8:30 p.m. Staff F stated Resident #1 had been restless after she administered the eye medication but she attempted to calm her prior to leaving the unit. Staff F stated she later responded to 2 quick buzzes from the pager indicating someone in the unit needed help immediately. Staff F stated upon entering the unit, she found Resident #1 on the floor and Staff E in tears. Staff F stated Staff E explained to her that both residents had wanted to get up so Staff E decided to take both residents down the hall with her to get Resident #2 merrywalker. Staff F stated Staff E explained to her that Resident #1 let go of her hand and fell . Staff F stated she assessed the resident and notified the resident's spouse who came to the unit. Staff F explained the resident had a large bump on the left temporal area so she applied ice to it and administered a pain pill to the resident. Staff F stated the resident's spouse did not want the resident sent to the hospital at that time. Staff F stated the resident did not show any change in mental status so she continued to do the neuro-checks until the night shift came on duty. Staff F stated once they applied the alarm after supper, Resident #1 no longer qualified as independent and the staff needed to apply a gait belt when assisted the resident with transfers or ambulation. During interview on 3/5/14 at 2:40 p.m., Staff G, LPN, revealed they worked the evening shift on 2/9/14. Staff G recalled hearing the buzzer go off sometime after supper and she responded by going to the SCU. Staff G stated upon her arrival the resident was on the floor and the charge nurse from South hall was already with the resident. Staff G stated she stayed briefly and felt Staff F had things under control. Staff G recalled Staff E told her Resident #1 lost balance and fell to the floor. Staff G stated almost all residents are to have gaitbelts used unless they really fight it and this information would be noted on their individual care plans. Staff G stated once staff applied the alarm to Resident #1 a gaitbelt should be used as the resident was no longer considered independent. During interview on 3/6/14 at 9:45 a.m., the director of nursing, DON revealed she became aware of the incident on 2/9/14 when she instructed the nurses to check with the resident's family regarding the decision to not hospitalize the resident. The DON stated the resident did get sent out to the hospital later that evening for evaluation and returned to the facility a few hours later. The DON stated Staff E should have had a gaitbelt with her at all times and could use it on anyone they assisted. The DON stated at the time she conducted the investigation Staff E expressed she would have had to let go of one of the resident's hands to sound the buzzer and the DON stated Staff E expressed she did not have time to do so as both residents decided to get up at the same time. Observation on 3/5/14 at 11:50 a.m., revealed the resident seated in a dining room chair with a personal safety alarm ( PSA ) and pressure pad alarm in place and tennis shoes on. At 12:30 p.m. and at 3:05 p.m., the resident sat in the recliner chair in the lobby area with pressure pad and PSA alarms engaged. The resident appeared calm and content. Observation on 3/6/14 at 8:25 a.m., revealed Staff D, CNA and the MDS Coordinator donned a gaitbelt around resident's waist and with 2 assistance stood the resident up from dining room chair and ambulated the resident over to the recliner chair in the lobby area. Once seated in the recliner, Staff D activated the PSA and pressure pad alarm for the resident's safety. Scant bruising was noted to the residents left temporal area.